The Silent Struggle Addressing Post-Stroke Psychological Challenges in Clinical Practice

Reecha Khadka

She is a licensed Clinical Psychologist and is recognized for her growing contributions to mental health care in Nepal. She holds an M.Sc. in Psychology from Banaras Hindu University and M.Phil. in Clinical Psychology from Tribhuvan University Teaching Hospital. She currently practices at UDM-NINAS, where she provides psychological assessment and therapy for individuals dealing with emotional challenges, trauma, and life transitions. Known for her warm, client-centered approach, she works across individual, couple, and family therapy-supporting clients in their journey toward healing and growth.

A 55-year-old woman who was active and emotionally strong survived a mild stroke. Months later, she became irritable, isolated herself, refused food, avoided eye contact and expressed suicidal thoughts and feelings of being a burden. Her post-stroke depression went unnoticed until psychological support and family education helped her rediscover hope and engagement—a story that reflects many unspoken struggles in Nepal.

In Nepal, emotional and cognitive challenges after stroke are often overlooked. Stroke care focuses mainly on physical recovery, with little or no structured psychological support. Mental health problems are dismissed or misunderstood, leaving many unscreened for depression, anxiety, or PTSD. This gap deeply affects survivors’ identity, independence, and well-being. Without psychological care, many face these invisible struggles alone. Addressing these needs is essential but hindered by a shortage of trained mental health professionals in the stroke care system.

A stroke arrives like a lightning bolt; sudden, life-changing, and often devastating. As the medical team starts to manage physical symptoms, the priority naturally falls on saving lives and restoring function. However, while this physical crisis is being addressed, another storm often brews quietly beneath the surface, one that cannot be seen on a scan or measured in lab results, yet can be just as disabling. This second storm manifests as anxiety that beats like a loud drum in the chest, depression like a dark shadow that follows everywhere, and memories that slip away like smoke in the wind. These “silent struggles” deeply impact the entire journey of recovery.

Globally, stroke is the second leading cause of death. In Nepal, stroke accounts for 7.6% of deaths and leads to long-term disability due to increasing risk factors like hypertension, smoking, and unhealthy lifestyles. Yet, emotional and cognitive needs are rarely addressed. To truly support survivors, we must shift from a biomedical model to a biopsychosocial one-restoring identity, emotional stability, and fostering hope. It is crucial to address both visible and invisible wounds early to ensure meaningful recovery.

Stroke survivors face more than just physical impairments; they also experience emotional, behavioral, and cognitive challenges. In the urgency of managing visible wounds, the unseen wounds are frequently overlooked. These wounds play a significant role in how survivors progress in rehabilitation, relate to others, and rebuild meaningful lives.

Emotional and behavioral disturbances after stroke arise from a complex mix of internal vulnerabilities and external stressors. Internally, survivors experience a cascade of emotional responses -shock, fear, guilt, or hopelessness triggered by sudden loss of bodily autonomy and uncertain futures. Early reactions may include denial or numbness. “One moment I was fine; the next, I couldn’t move my hand.” This loss often leads to depression (affecting nearly one-third), anxiety (35%), apathy, and emotional instability, all of which reduce motivation and energy.

Externally, survivors must grapple with shifting roles—from caregiver to care recipient which can trigger shame, worthlessness, or the feeling burdensome: “I used to do everything—now I’m a burden”. Disrupted routines, financial loss, and relationship disturbance exacerbate emotional suffering. Fear of rejection or appearing weak often silences emotional expression, especially in a country like ours where interdependence is highly valued.

Cognitive problems affecting memory, attention, and decision-making impact 20% to 80% of survivors. Survivors commonly say their thoughts are jumbled or unclear: “My mind doesn’t work like before”. Such impairments undermine confidence, communication, and independence. Caregivers may mistake forgetfulness for disinterest, isolating survivors further. Those with aphasia face even greater isolation and may disengage entirely. Without routine cognitive screening and caregiver education, these deficits often remain invisible and untreated.

Stroke is traumatic, with 17.5% developing post-traumatic symptoms like fear of recurrence and intrusive thoughts. More than half develop a fear of falling, often tied to emotional trauma and loss of confidence. Anger and irritability (15%–57%) often reflect struggles to regain control, not personality changes. If untreated, these emotions disrupt relationships and hinder therapy.

Here’s what every stroke care team can implement to move from silence to support:

Mental health screening as standard practice: Use tools like the PHQ-9, GAD-7, MoCA, WCST routinely like vital signs for early detection and support.

Provide evidence-based therapies: Use CBT, ACT, and mindfulness to help survivors reframe distress, build resilience, and find new meaning in their lives. Adapt approaches to cultural and educational backgrounds.

Address trauma, grief, and adjustment: Support emotional processing and identity rebuilding, validating the full emotional range after stroke.

Include family members in the healing process: Provide psychoeducation to reduce stigma, foster empathy, and support caregivers.

Promote behavioral activation: Encourage small, achievable goals to rebuild confidence and autonomy.

Prioritize emotional recovery as part of stroke care: Integrate clinical psychologists into stroke care teams, ensure mental health referrals at discharge, and provide long-term follow-up care.

Stroke recovery is not just about learning to walk again. It’s about learning how to live again—in a changed body, with a changed brain, in a life that often feels unfamiliar. The real damage isn’t only the bleed or clot, but the silence that follows: unspoken depression, invisible anxiety, grief, and identity loss which are real and treatable.

Clinicians, therapists, and caregivers must listen deeply, ask bravely, and treat holistically. Healing goes beyond the physical—it’s emotional, cognitive, relational, and existential.  By attending to the whole person rather than just their symptoms, survivors don’t just recover, but truly reclaim their lives.